Page 14 of 24 MET245_SOB_CA (01/26) Fs/f GCERT2010-DHMO-SOB sob Code Service Your and Your Dependent's Co-Payment D6194 Abutment supported retainer crown for FPD – titanium and titanium alloys. A retainer for a fixed partial denture that gains retention, support and stability from an abutment on an implant $520 D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys $510 D6197 Replacement of restorative material used to close an access opening of a screw- retained implant supported prosthesis, per implant. $30 Crowns/Fixed Bridges - Per Unit • An additional charge, not to exceed $150 per unit, will be applied for any procedure using noble, high noble or titanium metal. There is a $75 Co-Payment per molar, for the use of porcelain. • Cases involving seven (7) or more Crowns, implants and/or fixed Bridge units in the same treatment plan require an additional $125 Co-Payment per unit in addition to the specified Co-Payment for each Crown, implant or Bridge unit. D6205 Pontic – indirect resin based composite $245 D6210 Pontic – cast high noble metal $245 D6211 Pontic – cast predominantly base metal $245 D6212 Pontic – cast noble metal $245 D6214 Pontic – titanium and titanium alloys $245 D6240 Pontic – porcelain fused to high noble metal $245 D6241 Pontic – porcelain fused to predominantly base metal $245 D6242 Pontic – porcelain fused to noble metal $245 D6243 Pontic – porcelain fused to titanium and titanium alloys $245 D6245 Pontic – porcelain/ceramic $265 D6250 Pontic – resin with high noble metal $245 D6251 Pontic – resin with predominantly base metal $245 D6252 Pontic – resin with noble metal $245 D6253 Further treatment or completion of diagnosis necessary prior to final impression. Not to be used as a temporary pontic for a routine prosthetic restoration. $70 D6280 Implant maintenance procedures when a full arch removable implant/abutment supported denture is removed and reinserted, including cleansing of prosthesis and abutments – per arch This procedure includes active debriding of the implant(s) and examination of all aspects of the implant system, including the occlusion and stability of the prosthesis. The patient is also instructed in thorough daily cleansing of the implant(s). $55 D6545 Retainer – cast metal for resin bonded fixed prosthesis $100 D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis $100 D6549 Resin retainer – for resin bonded fixed prosthesis $75 D6600 Retainer inlay – porcelain/ceramic, two surfaces $245 D6601 Retainer inlay – porcelain/ceramic, three or more surfaces $245 D6602 Retainer inlay – cast high noble metal, two surfaces $245 D6603 Retainer inlay – cast high noble metal, three or more surfaces $245 D6604 Retainer inlay – cast predominantly base metal, two surfaces $245 D6605 Retainer inlay – cast predominantly base metal, three or more surfaces $245 D6606 Retainer inlay – cast noble metal, two surfaces $245 D6607 Retainer inlay – cast noble metal, three or more surfaces $245 D6608 Retainer onlay – porcelain/ceramic, two surfaces $245 D6609 Retainer onlay – porcelain/ceramic, three or more surfaces $245 D6610 Retainer onlay – cast high noble metal, two surfaces $245